Online Therapy Forum Application

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Online Therapy Institute/Online Coach Institute Forum Application

Name *
Affiliation/Name of Company
Address
Phone
Email Address *
Web Address *
Upload Your Resume (For Clinical Issued Disscussion Board applicants only)

If you offer mental health services online, are the services encrypted?		Yes No I don't know
Within the OTI Forum, are you interested in:		Clinical Issues Discussion Board Business Matters Discussion Board Both
If you are interested in the Clinical Issues Discussion Board please fill out the following:
Highest Degree Earned
Are you able to practice independently in your geographic location/jurisdiction?		Yes No
If not, are you engaged in clinical supervision?
Name of Clinical Supervisor
Do you agree to follow the terms and conditions of the OTI Forum?		Yes No